Healthcare Provider Details

I. General information

NPI: 1154499598
Provider Name (Legal Business Name): REZA NIKPOURFARD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 PRINCE FREDERICK BLVD
PRINCE FREDERICK MD
20678-3141
US

IV. Provider business mailing address

1240 SW 30TH AVE STE 309
MIAMI FL
33135-4731
US

V. Phone/Fax

Practice location:
  • Phone: 410-414-8333
  • Fax:
Mailing address:
  • Phone: 703-729-1818
  • Fax: 703-729-7776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15755
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401410408
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: